Background
Identifying Racial and Ethnic Disparities in
Admissions for Ambulatory Care Sensitive
Conditions among Medicare Beneficiaries
Presented by
Arthur J. Bonito, Ph.D.1; Celia R. Eicheldinger, M.S.1;
Arthur A. Meltzer, Ph.D.2, And Linda G. Greenberg, Ph.D.3
1RTI International; 2CMS; 3 AHRQ
Presented at
The 2005 Annual Research Meeting of AcademyHealth,
Boston, MA, June 28, 2005
3040 Cornwallis Road
Phone 919-541-6377
■
z
Limited information and few previously published
studies exist on access to care for minority Medicare
beneficiaries, other than African Americans, using
Medicare administrative claims data.
z
CMS sponsored this project to improve identification of
Asians and Hispanics, as well as to examine disparities
in health care access and use under Medicare.
z
Avoidable hospitalizations for ACSCs provide one
indication of limited access and receipt of less-thanadequate primary care.
P.O. Box 12194 ■ Research Triangle Park, NC 27709
Fax 919-990-8454
e-mail ajb@rti.org
RTI International is a trade name of
Research Triangle Institute
2
Ambulatory Care Sensitive Conditions
„
Study Goals
Hospital or Emergency Room (ER) admissions for 15
Ambulatory Care Sensitive Conditions (ACSCs) that
include the following :
z
Chronic (5) – chronic lung disease (asthma and
COPD), congestive heart failure, seizures,
diabetes, and hypertension
z
Acute (8) – cellulitis; bacterial pneumonia; urinary
tract infection; ulcers; hypoglycemia; hypokalemia;
dehydration; ear, nose, and throat infections
z
Preventable (2) – influenza and malnutrition
3
„
To improve accuracy of racial/ethnic identification of
Medicare beneficiaries to include: non-Hispanic
White, Black, Hispanic, Asian/Pacific Islander (A/PI),
and American Indian/Alaska Native (AI/AN).
„
To identify racial/ethnic disparities in hospital or
emergency room admissions for ACSCs.
4
Methods and Data
„
Data Limitations
Developed algorithm to more correctly identify Medicare
beneficiaries’ race/ethnicity:
z Used Spanish and Asian surname lists from US Census.
z From Medicare enrollment database (EDB), used first and
last name, race/ethnicity, language preference and place
of residence.
z Used common first names from web sources.
„
CMS obtains race/ethnicity data on Medicare
beneficiaries from SSA, which categorizes “Hispanic”
as a race code.
„
We present findings for AI/ANs despite underidentification on the EDB.
„
Used Medicare Part A claims for 2002 to estimate hospital
and ER admissions for ACSCs.
z
CMS has been working with IHS since 1999 to
improve identification of AI/AN beneficiaries.
„
Selected a stratified random sample of 1.96 million FFS
Medicare beneficiaries (over-sampling minorities).
z
Analyses show small predictable bias.
5
6
1
2002 Medicare FFS Study Sample
Race/Ethnicity
Sample
Medicare FFS
„
NH White
329,954
26,779,400
„
Black
328,246
3,053,618
„
Hispanic
534,196
720,664
„
A/PI
415,190
449,914
„
AI/AN
120,557
121,818
„
Other/Unknown
231,978
471,630
„
TOTAL
1,960,121
31,579,044
Analysis Approach
7
„
We examined hospital or ER admissions for each type of
ACSC - chronic, acute, preventable, and any.
„
We examined percentages with hospital or ER admission
by type of ACSC, race/ethnicity, sex, and age group.
„
The following tables include stacked bar graphs for each
type of ACSC by race, sex, and age.
8
Figure 1
Percentage of male Medicare beneficiaries with admissions for chronic
ambulatory care sensitive conditions by age group and race/ethnicity: CY 2002
Figure 2
Percentage of female Medicare beneficiaries with admissions for chronic
ambulatory care sensitive conditions by age group and race/ethnicity: CY 2002
5.95
6.70
5.53
6.00
5.60
85+
4.63
4.85
5.07
6.62
75-84
85+
5.00
75-84
5.49
65-74
4.83
< 65
3.54
4.99
4.12
3.43
4.53
3.05
2.46
5.06
3.50
2.94
2.50
3.72
2.54
1.44
6.78
4.50
White
4.48
Black
Hispanic
A/PI
5.44
5.09
3.70
White
AI/AN
Black
2.22
Hispanic
7.22
4.04
A/PI
AI/AN
Race/Ethnicity
Race/Ethnicity
9
4.79
1.41
8.19
5.83
65-74
< 65
5.52
10
Figure 3
Percentage of male Medicare beneficiaries with admissions for acute
Preliminary Results for Chronic ACSCs
ambulatory care sensitive condition by age group and race/ethnicity: CY 2002
„
Across all race/ethnicity groups, women have higher
percent of admissions for chronic ACSCs than men.
„
Typically, men and women under age 65 have higher
percent of admissions for chronic ACSCs.
„
Among elderly men and women (65 years of age and
over), admissions for chronic ACSCs increase with
age.
9.98
5.98
5.69
5.42
4.46
4.38
3.82
„
85+
75-84
65-74
< 65
7.07
A/PI and White beneficiaries have lowest percent of
admissions for chronic ACSCs, Blacks and AI/ANs
have the highest percent, Hispanics falls in between.
3.68
4.01
3.14
2.24
2.43
2.51
1.38
4.25
5.02
White
Black
4.04
Hispanic
5.22
3.20
A/PI
AI/AN
Race/Ethnicty
11
12
2
Figure 4
Percentage of female Medicare beneficiaries with admissions for acute
ambulatory care sensitive condition by age group and race/ethnicity: CY 2002
Preliminary Results for Acute ACSCs
„
Across all race/ethnicity groups, women have higher
percent of admissions for acute ACSCs than men.
„
Men and women age 85 and over have highest
percent of admissions for acute ACSCs.
„
Among elderly men and women, admissions for acute
ACSCs increase with age.
„
A/PI beneficiaries have lowest percent of admissions,
Blacks and AI/ANs have the highest, and Whites and
Hispanics fall in between.
9.38
7.42
6.50
5.61
6.44
85+
75-84
65-74
< 65
5.19
4.73
4.06
3.91
2.71
3.31
4.23
1.52
5.82
White
7.17
Black
5.27
Hispanic
5.00
2.34
7.93
3.93
A/PI
AI/AN
Race/Ethnicity
13
14
Figure 5
Percentage of male Medicare beneficiaries with admissions for preventable
Figure 6
Percentage of female Medicare beneficiaries with admissions for preventable
ambulatory care sensitive condition by age group and race/ethnicity: CY 2002
ambulatory care sensitive conditions by age group and race/ethnicity: CY 2002
0.10
0.15
0.14
0.11
0.11
0.08
0.09
0.09
0.10
White
0.06
0.10
65-74
< 65
0.04
0.04
0.04
0.05
0.03
0.03
0.10
Black
0.12
0.01
0.05
0.04
Hispanic
A/PI
0.04
0.07
0.03
0.09
75-84
0.13
0.08
0.04
0.04
85+
85+
75-84
65-74
< 65
0.08
0.21
0.06
0.03
0.03
0.06
0.10
0.15
0.10
0.06
White
AI/AN
Black
15
Hispanic
A/PI
AI/AN
Race/Ethnicity
Race/Ethnicity
16
Figure 7
Percentage of male Medicare beneficiaries with admissions for any
Preliminary Results for Preventable ACSCs
ambulatory care sensitive condition by age group and race/ethnicity: CY 2002
„
„
Across all race/ethnicity groups, women have a higher
percent of admissions for preventable ACSCs than
men.
13.00
Typically, among men and women – ages 85 and over
and under 65 – have the highest percent of admissions
for preventable ACSCs.
10.84
10.14
14.42
9.87
9.90
8.10
„
„
17
Typically, among elderly men and women, admissions
for preventable ACSCs increase with age.
7.23
85+
75-84
65-74
< 65
7.67
8.16
7.89
5.17
5.30
4.56
2.96
A/PI beneficiaries have lowest percent of admissions,
Blacks and AI/ANs have the highest, and Whites and
Hispanics fall in between.
11.05
7.76
White
Black
9.79
7.59
6.41
Hispanic
A/PI
AI/AN
Race/Ethnicity
18
3
Figure 8
Percentage of female Medicare beneficiaries with admissions for any
Preliminary Results for any ACSCs
ambulatory care sensitive condition by age group and race/ethnicity: CY 2002
14.02
11.59
75-84
10.36
11.38
„
Men and women ages 85 and over have highest percent of
admissions for all ACSCs combined.
„
Among elderly men and women, admissions for all ACSCs
combined increase with age.
„
A/PI beneficiaries have lowest percent of admissions,
Blacks and AI/ANs have the highest, and Whites and
Hispanics fall in between.
65-74
< 65
9.23
7.37
Across all race/ethnicity groups, women have higher
percent of admissions for all ACSCs combined than men.
14.63
85+
11.09
„
7.49
9.21
6.57
4.93
9.10
4.78
3.02
14.20
White
13.49
9.66
9.56
Black
Hispanic
7.40
A/PI
AI/AN
19
20
Summary of Preliminary Results
„
21
Conclusions
There is considerable consistency across the 15 individual
ACSCs and the four grouped -- chronic, acute, preventable
and any -- with respect to racial/ethnic differences in the level
of hospital or ER admissions, with age and sex controlled.
„
The improved race/ethnicity variable indicates sizeable and
consistent differences in admissions for ACSCs, suggesting
differences in access by some minority groups to timely and
appropriate primary care services.
z
Black and AI/AN beneficiaries have the highest levels of
ACSC hospital or ER admissions.
„
z
A/PI beneficiaries have the lowest level of ACSC hospital
or ER admissions.
More accurate coding for Hispanics and A/PIs allows a
unique opportunity to increase our knowledge of disparities
in health care use and outcomes.
„
z
Hispanic and White beneficiaries typically occupy the
middle ground, with lower levels of ACSC hospital or ER
admissions than Black and AI/AN, but higher than A/PI.
Additional research is needed, including multivariate
analysis to adjust for differences in SES, health status,
disease levels, as well as hospital, ER, outpatient, and
ambulatory care service use.
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